Login
Agency Information
Name
Address 1
Address 2
City
State
Zip Code
Agency Contacts
Contacts (Name, Title, Phone Number and Email address)
Programs
Please select the programs / services your agency provides
ODP - Traditional
Assistive Technology
Base Services NOS
Behavioral Supports
Chore Services
Communication Specialist
Community Inclusion
Community Integration
Community Participation Support
Companion Services
Day Habilitation
Early Intervention
Family Aide
Home Accessibility Adaptations
Homemaker
In-Home and Community Supports
Intermediate Care Facility
Lifesharing
Nursing
Residential
Respite
Small Group Employment
Supplemental Habilitation
Supported Employment
Supported Living
Transportation
Vehicle Accessibility Adaptations
Other programs / services
Number of monthly claims
(if a claim has multiple units, it should still be considered as 1 claim)
ODP - Agency With Choice
Companion Services
Homemaker
In-Home and Community Supports
Monthly Administrative Fee
Participant-Directed Goods and Services
Recreation
Respite
Supported Employment
Other programs / services
Number of monthly claims
(if a claim has multiple units, it should still be considered as 1 claim)
ODP - Autism Services
Job Finding
Residential
Supported Employment
Other programs / services
Number of monthly claims
(if a claim has multiple units, it should still be considered as 1 claim)
Additional Information
What is your agency's approximate annual revenue?
Which EMR / EHR system (if any) does your agency currently use?
Which EVV system (if any) does your agency use?
Are you also interested in a quote to outsource the billing process?
Yes
No
Is there any other information you would like to share with us?
Send
